NCLEX-RN
NCLEX RN Exam Questions Questions
Extract:
Question 1 of 5
Pin care is a part of the care plan for a client who is in skeletal traction. When assessing the site of pin insertion, which one of the following findings would the nurse know as an indicator of normal wound healing?
Correct Answer: B
Rationale: Exudate (moist, active drainage) is a clinical sign of wound infection. Crust (dry, scaly) is part of the normal stages of wound healing and should not be removed from around the pin site. It usually sloughs off after the underlying tissue has healed. Edema (swelling) is a clinical sign of wound infection. Erythema (redness) is a clinical sign of wound infection.
Question 2 of 5
The nurse is teaching a client with a new colostomy about appliance care. Which instruction should be included?
Correct Answer: B
Rationale: Emptying the colostomy pouch when one-third to one-half full prevents leakage and skin irritation. Changing every 12 hours is excessive, soap may leave residue, and lotion can interfere with adhesion.
Question 3 of 5
The nurse is conducting a physical assessment on a client with mild anemia. Which of the following would the nurse expect to observe?
Correct Answer: C
Rationale: Mild anemia reduces oxygen-carrying capacity leading to fatigue and activity intolerance. Heart murmurs increased respiratory rate or frequent infections are not typical findings in mild anemia unless complications arise.
Question 4 of 5
The nurse is teaching a client with a history of gout about medication adherence. The nurse should tell the client to:
Correct Answer: A
Rationale: Allopurinol reduces uric acid levels in gout, so adherence is critical to prevent flares.
Question 5 of 5
The nurse is caring for a client with a history of ectopic pregnancy. Which risk factor is most likely to be present?
Correct Answer: A
Rationale: Pelvic inflammatory disease (PI
D) is a major risk factor for ectopic pregnancy as it can scar the fallopian tubes impairing embryo transport. Gestational diabetes hypertension and multiple gestations are not strongly associated.